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Mohamed B, Yarlagadda K, Self Z, Simon A, Rigueiro F, Sohooli M, Eisenschenk S, Doré S. Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options. Transl Stroke Res 2024; 15:239-332. [PMID: 36922470 DOI: 10.1007/s12975-023-01123-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 03/18/2023]
Abstract
Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.
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Affiliation(s)
- Basma Mohamed
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Keerthi Yarlagadda
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Zachary Self
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Alexandra Simon
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Frank Rigueiro
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Maryam Sohooli
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Departments of Neurology, Psychiatry, Pharmaceutics, and Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
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Klobučníková K, Kollár B, Jurík M, Valovičová K, Hardoňová M, Poddaný M, Tedla M, Riant M, Klail P, Turčáni P, Šiarnik P. No Difference in Sleep Desaturations Severity between Patients with Wake-Up and Non-Wake-Up Stroke: A PRESS Study Results. Life (Basel) 2023; 13:life13020517. [PMID: 36836872 PMCID: PMC9959436 DOI: 10.3390/life13020517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Wake-up stroke (WUS) is a certain type of ischemic stroke in which a patient wakes up with a new neurological deficit due to cerebral ischemia. Sleep-disordered breathing is an independent risk factor for stroke, but the role of nocturnal oxygen desaturation in the pathophysiology of WUS is still insufficiently explored. According to several studies, patients with WUS have a significantly more severe sleep apnea syndrome and lower mean blood oxygen saturation. This study aimed to assess the severity of nocturnal desaturations in acute WUS and non-WUS patients using nocturnal pulse oximetry. MATERIAL AND METHODS The cohort of 225 consecutive patients with neuroimaging-verified acute cerebral ischemia was prospectively enrolled. For further analyses, 213 subjects with known WUS/non-WUS status were selected (111 males and 102 females, average age 70.4 ±12.9, median baseline NIHSS = 5, median baseline mRS = 3). Patients were divided into the WUS group (n = 45) and the non-WUS group (n = 168). Overnight pulse oximetry was performed within 7 days of the stroke onset and data of both of the studied groups were compared. RESULTS We found oxygen desaturation index (ODI) in the WUS group was 14.5 vs. 16.6 (p = 0.728) in the non-WUS group, basal O2 saturation was 92.2% vs. 92.5% (p = 0.475), average low O2 saturation was 90.3% vs. 89.6% (p = 0.375), minimal O2 saturation was 79.5% vs. 80.6% (p = 0.563), and time with O2 saturation <90% (T90) was 4.4% vs. 4.7% (p = 0.729). CONCLUSIONS In the studied sample, monitored respiratory parameters including ODI, basal O2 saturation, average low O2 saturation, minimal O2 saturation, and T90 did not significantly differ between groups of WUS and non-WUS patients.
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Affiliation(s)
- Katarína Klobučníková
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
| | - Branislav Kollár
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
- Correspondence: ; Tel.: +421-2572-90147
| | - Matúš Jurík
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
| | - Katarína Valovičová
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
| | - Miroslava Hardoňová
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
| | - Michal Poddaný
- Department of Neurology, General Hospital, 031 23 Liptovsky Mikulas, Slovakia
| | - Miroslav Tedla
- Department of ENT and HNS, Faculty of Medicine, University Hospital Bratislava, Comenius University, 814 69 Bratislava, Slovakia
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2T8, UK
| | - Michal Riant
- Department of Otorhinolaryngology, University Hospital, Faculty of Medicine in Pilsen, Charles University, 100 00 Prague, Czech Republic
| | - Pavel Klail
- Department of Otorhinolaryngology, University Hospital, Faculty of Medicine in Pilsen, Charles University, 100 00 Prague, Czech Republic
| | - Peter Turčáni
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
| | - Pavel Šiarnik
- 1st Department of Neurology, Faculty of Medicine, Comenius University, 814 69 Bratislava, Slovakia
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A prospective study of wake-up stroke patients presenting to the emergency department: a single-center cohort study. Ir J Med Sci 2023; 192:409-416. [PMID: 35391655 DOI: 10.1007/s11845-022-02995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study aims to prospectively examine patients with ischemic wake-up stroke (WUS) presenting to the emergency department, to investigate the risk factors affecting the mortality occurring within 28, 90, and 180 days, and to create a new scoring system for the prediction of 28-day mortality. MATERIALS AND METHOD Patients who presented to the emergency department with WUS findings between 01.07.2019 and 30.06.2020 were prospectively analyzed. Logistic regression analysis was performed to determine the factors affecting mortality and the modified Rankin scale (mRS). RESULTS A total of 161 patients were included. Of the patients, 22.4% died within 28 days and 40.4% within 180 days. The presence of coronary artery disease (CAD) increased the 28-day mortality risk (p = 0.009) 3.57 times, 90-day mortality risk 2.15 times (p = 0.033), and 180-day mortality risk 2.18 times (p = 0.045). In order to be used in the prediction of 28-day mortality in patients with WUS, we developed the ischemic WUS mortality score (IWUSMOS), which consists of the middle cerebral artery (45 points), internal carotid artery (60 points), basilar artery (39 points), superior cerebellar artery (66 points) occlusion, hypertension (33 points), CAD (28 points), malignancy (100 points), and arrhythmia (23 points). With this scoring system, the 28-day mortality risk was determined as 0.05% when the total score was "43" whereas the mortality risk was found to be 95.0% when the total score was "187." CONCLUSION We propose that IWUSMOS, a new scoring system, can be used to predict the 28-day mortality risk of patients with WUS.
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Hong Y, Mo H, Cho SJ, Im HJ. Wake-up ischemic stroke associated with short sleep duration and sleep behavior: A stratified analysis according to risk of obstructive sleep apnea. Sleep Med 2023; 101:497-504. [PMID: 36527941 DOI: 10.1016/j.sleep.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Wake-up stroke (WUS) is an ischemic stroke occurring during nocturnal sleep with neurological deficits observed upon awakening. Our study aimed to investigate the association between WUS, sleep curtailment, and sleep behavior according to the obstructive sleep apnea (OSA) risk in patients with acute ischemic stroke. METHODS This single-centered, retrospective study included hospitalized subjects with acute ischemic stroke occurring within 30 days. A total of 250 participants were classified as WUS or not and enquired about their sleep habits concerning sleep time on weekdays and weekends, demographic factors, and assessed comorbid medical conditions. Weekend catch-up sleep (CUS) was defined as the extension of sleep duration during weekends. The average weekly sleep duration and chronotype were assessed. The association between WUS and sleep factors was analyzed. RESULTS WUS was observed in 70 patients (28.0%) with acute ischemic stroke. There were no significant differences in the demographic and stroke-related variables between the WUS and non-WUS (NWUS) groups. Upon stratified analysis based on risk of OSA, average weekly sleep duration (odds ratio, [OR] = 0.60, 95% confidence interval, [CI] = 0.41-0.89; p = 0.011), the presence of weekend CUS (OR = 0.07, 95% CI = 0.01-0.97; p = 0.047), and chronotype (OR = 0.62, 95% CI = 0.39-0.98; p = 0.041) were independently associated with WUS in low-risk group with OSA, but not in the high-risk group. CONCLUSIONS Short sleep duration and lack of compensation are significantly associated with WUS in low-risk OSA group. Insufficient sleep and sleep behaviors could play a different role in causing ischemic stroke during sleep when patients are stratified by their risk of sleep apnea.
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Affiliation(s)
- Yooha Hong
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Heejung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Hee-Jin Im
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea.
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Lu X, Liu W, Wang H. Investigating the Association between Wake-Up Stroke and Obstructive Sleep Apnea: A Meta-Analysis. Eur Neurol 2021; 85:14-23. [PMID: 34518455 DOI: 10.1159/000517916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Management of wake-up stroke (WUS) is always a challenge as no clear time of onset could be ascertained, and how to choose an appropriate therapy remains unclear. Sleep-disordered breathing (SDB) has been regarded as a potential risk factor to WUS, yet no consensus was achieved. Motivated by the need for a deeper understanding of WUS and its association with sleep apnea, meta-analyses summarizing the available evidence of respiratory events and indices were conducted, and sensitivity analysis was also used for heterogeneity. METHODS Electronic databases were systematically searched, and cross-checking was done for relevant studies. Collected data included demographic characteristics, and sleep apnea parameters were extracted with stroke patients divided into WUS and NWUS groups. Clinical data of stroke patients accompanied with sleep apnea syndrome (OSA, SAS, and severe SAS) were also extracted for meta-analysis. RESULTS A total of 13 studies were included in the analysis. The meta-analysis results showed that OSA, SAS, and severe SAS were significantly higher in WUS patients. A significantly higher AHI (WMD 7.74, 95% CI: 1.38-14.11; p = 0.017) and ODI (WMD of 3.85, 95% CI: 0.261-7.438; p = 0.035) than NWUS patients was also observed in the analysis of respiratory indices. CONCLUSION WUS patients have severer SDB problems compared to NWUS patients suggesting that respiratory events during sleep might be underlying the induction of WUS. Besides, the induction of WUS was significantly associated with men rather than women. Therefore, early diagnosis and management of potential WUS patients should benefit from the detection of SDB status and respiratory effects.
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Affiliation(s)
- Xin Lu
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wenhong Liu
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Hui Wang
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Abstract
PURPOSE OF REVIEW Stroke and sleep apnea are highly prevalent conditions with a physiologically plausible bidirectional relationship. This review addresses prestroke sleep apnea, wake-up stroke and sleep apnea, and poststroke sleep apnea, with an attempt to highlight research published in the last 18 months. RECENT FINDINGS Sleep apnea is highly prevalent poststroke. Poststroke sleep apnea is associated with worse poststroke functional and cognitive outcomes and a higher risk of recurrent stroke. Physiologic tests are needed to diagnose sleep apnea in poststroke patients as sleep apnea questionnaires do not perform well in this population. The role of CPAP in poststroke management is not yet well established. SUMMARY Sleep apnea is a well established independent risk factor for stroke that confers an approximately two-fold increased risk of incident stroke. Sleep apnea is highly prevalent poststroke and is associated with worse outcomes after stroke. Sleep apnea is an attractive target for research addressing secondary stroke prevention and recovery.
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Park J, Yeo M, Kim J, Kim S, Lee SH, Kwon S, Shin DI, Lee S, Lee SY. Sleep-disordered breathing and wake-up stroke: a differential association depending on etiologic subtypes. Sleep Med 2020; 76:43-47. [DOI: 10.1016/j.sleep.2020.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/07/2020] [Accepted: 09/29/2020] [Indexed: 12/17/2022]
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Zhang YL, Zhang JF, Wang XX, Wang Y, Anderson CS, Wu YC. Wake-up stroke: imaging-based diagnosis and recanalization therapy. J Neurol 2020; 268:4002-4012. [PMID: 32671526 DOI: 10.1007/s00415-020-10055-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 02/08/2023]
Abstract
Wake-up stroke (WUS) is a subgroup of ischemic stroke in which patients show no abnormality before sleep while wake up with neurological deficits. In addition to the uncertain onset, WUS patients have difficulty to receive prompt and effective thrombolytic or reperfusion therapy, leading to relatively poor prognosis. A number of researches have indicated that CT or MRI based thrombolysis and endovascular therapy might have benefits for WUS patients. This review article narratively discusses the pathogenesis, risk factors, imaging-based diagnosis and recanalization treatments of WUS with the purpose of expanding current treatment options for this group of stroke patients and exploring better therapeutic methods. The result showed that multimodal MRI or CT scan might be the best methods for extending the time window of WUS and, therefore, a large proportion of WUS patients could have favorable prognosis.
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Affiliation(s)
- Yu-Lei Zhang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Jun-Fang Zhang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Xi-Xi Wang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Yan Wang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | | | - Yun-Cheng Wu
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China.
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Fu X, Li J, Wu JJ, Chen J, Huang JY, Mao CJ, Chen R, Liu CF. Reduced cortical arousability to nocturnal apneic episodes in patients with wake-up ischemic stroke. Sleep Med 2020; 66:252-258. [DOI: 10.1016/j.sleep.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/26/2019] [Accepted: 09/13/2019] [Indexed: 01/22/2023]
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Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) is increasing in prevalence. The intermittent hypoxia of OSA has wide-ranging effects on a patient's general health outcomes. However, gold-standard investigations and treatment are expensive and a significant burden on patients. Therefore, OSA research remains focused on improving the means of diagnosing and treating OSA, in high-risk-associated conditions. This review is to provide an update on the advances in the field of OSA. RECENT FINDINGS There has been recent debate about the best practice for diagnosis and treatment of OSA. Further work has been done on conditions associated with OSA including hypertension, atherosclerosis, various types of dementia and intracranial aneurysms. Inflammatory and vascular risk factors associated with OSA increase stroke risk and alter outcomes for recovery. OSA should definitely be considered in patients presenting with nonarteritic anterior ischemic optic neuropathy, and perhaps those with intracranial hypertension. SUMMARY Newer home-based sleep-apnea testing can be implemented via physician clinics, with oversight by a certified sleep physician. Although continuous positive airway pressure (CPAP) is the gold-standard, management should include diet and exercise. It is important to test for, and treat OSA in patients with a range of neurological diseases. However, further studies into the long-term impact of CPAP on health outcomes are still needed.
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Obstructive sleep apnea and ischemic stroke: a risk assessment. Neurol Sci 2019; 40:2183. [DOI: 10.1007/s10072-019-03946-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/22/2019] [Indexed: 02/03/2023]
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Xu J, Qin Z, Li W, Li X, Shen H, Wang W. Effects of somatotropic axis on cognitive dysfunction of obstructive sleep apnea. Sleep Breath 2019; 24:175-182. [PMID: 31073904 DOI: 10.1007/s11325-019-01854-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is associated with a variety of neuroendocrine disorders and may lead to many complications, including cognitive dysfunction. The aim of this study was to assess the change of somatotropic axis and to detect the relation between somatotropic axis hormone and cognitive dysfunction. METHODS Sixty-six patients with OSA and 16 healthy controls were enrolled in this cross-sectional study. Cognitive function assessment using the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) and polysomnography were performed on all individuals. Blood samples were taken the next morning following the polysomnography and the level of serum growth hormone-releasing hormone (GHRH) and growth hormone (GH) were analyzed by enzyme-linked immunosorbent assay. RESULTS Compared with the control group, OSA patients showed significantly lower serum GH level (p < 0.05), whereas no statistical significance of GHRH level was found. In addition, lower MMSE and MoCA scores were found only in the severe OSA patients when compared with the controls. Furthermore, in severe OSA patients with cognitive dysfunction (MMSE score < 27 and MoCA score < 26), serum GHRH and GH levels were significantly lower than those without cognitive dysfunction. Logistic analysis revealed that cognitive dysfunction in severe OSA patients was associated with micro-arousal index and the level of serum GHRH and GH. CONCLUSION Decreased serum GH and GHRH levels were found among severe OSA patients with cognitive dysfunction who were overweight, which might promote the occurrence of cognitive dysfunction.
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Affiliation(s)
- Jiahuan Xu
- Institute of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Zheng Qin
- Institute of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Wenyang Li
- Institute of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Xiaomeng Li
- Institute of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Hui Shen
- Institute of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Wei Wang
- Institute of Respiratory and Critical Care Medicine, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China.
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